health is wealth: health care access for dalit communities

Health is Wealth: Health Care Access for Dalit communities in Saptari, Nepal

Workshop in Development Practice

School of International and Public Affairs

Columbia University

Tsufit Daniel

Nadia Hasham

Kiryn Lanning

Mai Shintani

Vivek Yadav

Health is Wealth, 1

Table of Contents

I. Executive Summary.............................................................................................................3

II. Acronyms and Abbreviations..............................................................................................4

III. Introduction………..…..……………………………………………………...…………...5

IV. Country Context…………………………………………………………………………...6

4.1 Political Context...………..………………………………………….…………..…6

4.2 Economic Context………..………………………………………………….……..6

4.3 The Terai…………………..………………………………………………………..7

4.4. Dalits of Nepal…………….……………………………………………………….8

4.5 The Health Situation………………………...……………………………………...9

4.6 Human Rights and Health care Access for Dalits………...……………………….10

4.7 Dalits and Health care Access…………………………………………..…………12

4.8 Millennium Development Goals…………………………...……………………...14

4.9 Nepal Public Health Sector………………………………………………………..14

4.10 Non-State Health Sector………………………………………………..………..16

4.11 Health Policy Overview………………………………………………………….17

V. Objectives..........................................................................................................................20

VI. Methodology......................................................................................................................21

VII. Limitations........................................................................................................................23

VIII. Key Findings......................................................................................................................25

8.1 Structure………………………………………………………………………..…25

8.2 Perceptions……………………………………………………..……..………..…26

8.3 Information Access…………………………………………………..….……..…27

8.4 Physical Access…………………………………………………………………...28

8.5 Financial Access…………………………………………………………….…….29

8.6 Social Capital………………………………………………………………..……32

8.7 Discrimination…………………………………………………………………….32

IX. Recommendations............................................................................................................. 34

9.1 Policy Advocacy………………………………………………………………..…34

9.2 Partnerships……………………………………………………..……..………..…35

9.3 Strategy……………………………………………………………………………37

X. Conclusions....................................................................................................................... 41

Health is Wealth, 2

XI. Bibliography……………………………………………………………………………..42

Annex 1: Background – Tables and Maps……………………………………………………….45

Annex 2: Map of Communities…………………………………………………………………..47

Annex 3: Table of Timeline of Relevant Policies, Plans, Framework, and Agendas….………...48

Annex 4: Stakeholder Analysis…………………………………………………………………..49

Annex 5: Institutional Analysis………………………………………………………………….57

Annex 6: List of Interviews and FGDs Conducted……………………………………………....62

Annex 7: Survey…………………………………………………………………………………63

Annex 8: Common Diseases in Dalit and Non-Dalit Communities in Saptari District……….…66

Health is Wealth, 3

I. Executive Summary Historically, Dalits have been socially, economically, and politically discriminated against within

Nepal. In order to address issues of historical marginalization, the government of Nepal has

created health care provisions such as the National Health Sector Program – Implementation

Plan II (2010- 2015) that aim to directly mitigate vulnerabilities for marginalized groups as they

pertain to health care access. Despite the national efforts to create inclusive health care policies

there remains concern regarding health care access for Dalits in the Saptari District of Nepal.

This research examines health care access for Dalits in six communities of Saptari, as defined by

five dimensions of access: physical access, information access, financial access, discrimination,

and social capital. Within the six selected communities, nineteen focus group discussions and

nineteen key informant interviews were conducted with a total of 209 participants.

Based on these five dimensions of access, Dalits reported they lacked access to health care due to

information, physical, and financial barriers, discrimination, and the lack of social capital in

comparison to non-Dalits. Dalits lacked information regarding health education on causes,

symptoms, and treatments for diseases when contrasted with non-Dalits. Dalits were also less

aware of available health care services. Both Dalits and non-Dalits reported lacking information

regarding medicines and incentives provided by the health care system. Dalits lacked physical

access to higher level health care services in comparison to non-Dalits who typically bypassed

lower level health facilities for care and obtained care at either zonal or district hospitals and

primarily private clinics. Both Dalits and non-Dalits highlighted the importance of proximity to

health facilities as a physical access indicator. Dalits and non-Dalits similarly emphasized the

importance of social capital as a key coping mechanism – the ability to utilize social networks

and relationships for information and greater access to incentives, services, and loans. There

were few explicit examples of direct caste-based discrimination at the point of service delivery;

however, there were accounts of discrimination in access to health care and entitlement to

specific government incentives for marginalized groups. Discussions around caste illuminated

this duality of caste as economic status. Both ‘Dalit’ and ‘poor’ were used interchangeably,

thereby exemplifying the complexity of caste based discrimination not as an explicit barrier to

equity but a subversive, sometimes systemic or culturally compounded, marginalization. Finally

both Dalits and non-Dalits reported financial accessibility as a barrier to health care access. The

situation of Dalits was exacerbated by high interest rates on loans and lack of information

regarding financial incentives targeted to marginalized groups, often resulting in increased

health-related expenses. Therefore, the major finding of the research lies in the nexus of

socioeconomic factors that contributes to the poorer health status of Dalit communities and their

limited access to health care services.

Acknowledging the limitations of this study, the implications of the findings highlight the need

for increased education and outreach for effective policy implementation of National Health

Sector Program – Implementation Plan II. These findings also emphasize the need for policy

makers to include Dalits in decision-making at the local level. It is recommended that Samata

Foundation advocate for innovative grassroots approaches that address the needs of local

communities. It is advised that the government strengthen internal and external-monitoring

mechanisms, which will increases transparency and accountability, through strategic

partnerships.

Health is Wealth, 4

II. Acronyms and Abbreviations

District Development Committee DDC

District Health Office DHO

Essential Health Care Services EHCS

Expanded Program on Immunization EPI

External Development Partners EDP

Female Community Health Volunteer FCHV

Focus Group Discussion FGD

Gender Equality and Social Inclusion Strategy GESI

Health Center HC

Health Post HP

Information Education and Communication Programme IEC

International Non-Governmental Organization INGO

Key Informant Interview KI

Millennium Development Goal MDG

Ministry of Health MoH

Nepal Health Sector Program- Implementation Plan NHSP-IP

Nepal Health Sector Program- Implementation Plan II NHSP-II

Nepal Human Development Report NHDR

Non-Governmental Organization NGO

Primary Health Center PHC

Second Long Term Heath Plan SLTHP

Sub-Health Post SHP

Traditional Birth Attendant TBA

United Nations Children’s Fund UNICEF

Village Development Committee VDC

World Health Organization WHO

Health is Wealth, 5

III. Introduction Samata Foundation, formerly known as Nepal Centre for Dalit Study, is a Nepali think tank

committed to ensuring equitable justice, rights, and development for all marginalized

communities, especially the Dalit community in Nepal. Established in 2008, their work primarily

focuses on policy research and advocacy for the rights of Dalits, historically considered the

untouchable caste by Hindu tradition. The Foundation aims for social inclusion of all

marginalized peoples and to end discrimination in Nepali society and politics by disseminating

knowledge through research and publications, advising policy makers, encouraging civic

participation, and empowering individuals from the Dalit community to become the next

generation of leaders.

Working in

collaboration with

Samata Foundation, a

five-person team

from Columbia

University’s School

of International and

Public Affairs

conducted a seven-

month research

project on the health

status of Dalits in the

Terai region.

Research teams were

deployed in January

and March 2012 to

conduct key

informant interviews,

community

observations, and site

visits to health

facilities as well as

focus group

discussion. This

ethnographic research

examined five

dimensions of health care access for Dalits in six communities in the Terai.

With the advance of the deadline of Nepal’s constitutional reform, the development of this

research arrives in an opportune time. It is hoped that health policymakers in Nepal would find

the analysis and findings of this research helpful in approaching health policy and delivery of

health services in a way that achieves social inclusion of marginalized communities and

addresses the human rights of Dalit communities.

Health is Wealth, 6

IV. Country Context

4.1 Political Context

Nepal has been in a state of perpetual political turmoil for approximately the past fifteen years.

Today, Nepal continues to rebuild from the consequences of this political unrest.

The monarchy exercised uninterrupted and absolute domination over Nepal until 1991 when, due

to growing political pressure from a people’s movement, His Majesty King Birendra was forced

to institute a house of representatives with limited powers. Despite this gesture, the Maoists

continued their armed struggle against the state and in 1996 this struggle erupted into war. The

ensuing decade-long people’s war decisively altered the political landscape of Nepal by

mobilizing marginalized groups on an unprecedented scale. The immediate result of the final

armed offensive was one of the most celebrated upsurges of recent times: the “Jan-Aandolan II”,

a non-violent people’s movement in 2006. This people’s movement, which was led by an

alliance of seven political parties, overthrew the monarchy and ushered in the secular,

democratic republic of Nepal.1

Nepal’s fledgling democratic experiment has been offset by a series of political party turnovers

and political conflicts. Despite these disruptions, two positive developments have taken place

over the past five years arguing for stable democracy in the future. First, the Maoists have

demilitarized in cooperation with the electoral process, which resulted in a political triumph

during the 2008 elections, during which the Maoist party of Nepal came to power at the center.

Second, the rise of regional political parties, particularly in the Madhesh region, has given a new-

found voice to a broad range of social groups, which had historically been excluded from

political participation. The resulting political mobilization by a variety of interested stakeholders

has heightened the interest and attention to the Nepali political structure and function. This level

of invested interest has allowed democracy to take root in Nepal in a relatively short period of

time. The most recent report on the State of Democracy in South Asia demonstrates a robust

belief in democracy among the people of Nepal.2 These regional and ethnic democratic

aspirations are expected to find concrete articulation in the new constitution, which is due by the

end of May 2012.

4.2 Economic Context

Nepal is one of the poorest countries in the world with as much as 40 percent of its population

still below the poverty line, as indicated by the latest Human Development Index (HDI) report of

1S. Einsidel, D. Malone and S. Pradhan, Nepal in Transition: From People’s War to Fragile Peace (London:

Cambridge University Press, 2012). 2 Centre for the Study of Developing Societies, State of Democracy in South Asia (New Delhi: Oxford Univesity

Press India, 2007).

Health is Wealth, 7

2011, which ranked Nepal 157th

among 187 countries.3 Agriculture is 40 percent of Nepal’s

national GDP and manufacturing is less than 15 percent.4 The diminished role of the

manufacturing sector in Nepal’s economy is a direct consequence of the civil war, which resulted

in a flight of both domestic and foreign investors. Furthermore, the continuing state of political

instability has done little to restore investor confidence. Lack of investment combined with a

severe paucity of skilled labor, has resulted in Nepal’s slow economic recovery.5

4.3 The Terai

Nepal is divided into three main geographical regions from the North to the South: “Mountain”,

“Hill”, and “Terai”. The research presented here was conducted in the Terai, which is a narrow

strip of fertile alluvial plains running East to West across Nepal and continuing into the Gangetic

plains of North India. The Terai constitutes only about 23 percent of Nepal’s total land-area but

is inhabited by close to half of its population; this is the most densely populated region in Nepal.6

The cultural and linguistic diversity of the Terai is due to its regional proximity to neighboring

communities in India. The population of Terai is classifiable into three categories: Indigenous

groups or Jana-jati, Madhesis or communities with extensive cultural and linguistic cross-border

links, and the Hill migrants, now the largest sub-population.7 The Terai is the backbone of the

national economy, accounting for close to 60 percent of the agricultural land and contributing to

over two thirds of the country’s GDP.8

Madhesi communities have historically been discriminated against as second-class citizens

within Nepal.9 The “Nepali” identity has traditionally been considered the culture of hill-

dwelling higher Chhettri-Brahmin castes often excluding other regional cultural identities.10

Education across Nepal, for most of its modern history, was conducted in Nepali, a language not

understood by most of the inhabitants of Terai.11

Inhabitants of the region were denied

citizenship rights in other examples, on the pretext that they were Indian immigrants.12

However,

in 2007, led by regional political parties and rallying under the identity of “Madhesi”, people in

the region were successful in articulating their concerns and staking a claim in the political

process underway at the center. The “Madhesi movement” marked a turning point in the politics

of the region and brought the issue of federalism to the center-stage of Nepali politics.

3 United Nations Development Programme, Human Development Report 2011,- Sustainability and Equity: A Better

Future for All (New York, NY: Palgrave Macmillan, 2011). 4Y. Ghimire and S. Sharma, Nepal: Country Study Report (Kathmandu, Nepal: IIDS, 2002). 5 The World Bank, Nepal Economic Update 2011. Web. 25 April 2012.

<http://siteresources.worldbank.org/NEPALEXTN/Resources/2235541296055463708/NepalEconomicUpdate11920

11.pdf>. 6 J. Miklian and International Institute for Peace and Conflict Research, Nepal's terai: constructing an ethnic conflict

(Oslo, Norway: International Peace Research Institute, 2008). 7Ibid 8 Economist Intelligence Unit, Nepal: Country Report 2006. Web. 25 April 2012.

<http://www.un.org.np/sites/default/files/report/tid_188/2006-march-EIU_Nepal_March06.pdf>. 9Samata Foundation, Confusion in Dalit Transformation in the New Constitution. SAMATA Policy Paper-1

(Kathmandu, 2010). 10M. Lawoti, Contentious politics and democratization in Nepal (New Delhi: Sage, 2007). 11 Ibid 12U. Sigdel, Citizenship Problem of Madhesi Dalits (Kathmandu: Social Inclusion Reseach Fund, 2006).

Health is Wealth, 8

4.4 The Dalits of Nepal

“Dalit”, literally meaning “oppressed”, is a self-label employed by low-caste groups across South

Asia, especially for the purposes of political mobilization.13

In Nepal, Dalits constitute between

13 and 20 percent of the population and consist of more than 20 caste groups. These numbers are

subject to debate owing to the fact that the Nepal decennial census does not collect caste-

disaggregated data.14

Belonging to the lowermost strata of the Hindu hierarchy, the caste groups

generally subsumed under this label were until recently considered to be untouchables due to

their perceived ritual impurity. While the actual practice of untouchability is in decline

throughout Nepal, caste prejudices still exist and appear to be quite strong in areas such as

marital practices. More importantly, such discriminatory practices have compounded as a result

of the historical marginalization of Dalits, often resulting in the exclusion of participation within

the public sphere.15

Therefore, very few Dalits have traditionally engaged in politics, while still

fewer have been elected to political office or other public positions. Such social disadvantage is

further compounded by economic hardship. According to one estimate, 40 percent of Dalits are

landless laborers. Although exact figures are elusive, poverty statistics for Dalits are estimated to

be considerably higher than national averages, as demonstrated by the economic welfare

indicators in Table 1.

Table 1: Economic Indicators of Welfare, Dalit Populations compared to National (2001)

INDICATORS NATIONAL DALIT

Under-five mortality rate (per

1,000 live births)

104/1000 171.2/1000

Infant mortality rate (per

1,000 live births)

75.2/1000 116.5/1000

Fertility rate (per woman of

child bearing age)

4 4.07

Literacy Rate (%) 54 33

Average Years of schooling 3.62 2.1

High school graduates and

above (%)

17.6 3.8

Graduates (college) and

above (%)

3.4 0.4

Poverty (% of population

below national poverty line)

31 47

Landless households (%) 13 47% (Terai); 15% (Hill)

Source: Thapa, N. (2009)

13M. Lawoti, Government and Politics in South Asia (Michigan: Westview Press, 2008) 14N. Thapa, Country Profile of Excluded Groups in Nepal: Draft (Kathmandu, 2009). Web. 13 Feb. 2012.

<http://www.unescap.org/ESID/hds/development_account/mtg/EGM_Bg_doc/Nepal%20020909.pdf>. 15 United Nations Development Programme, The Dalits of Nepal and a New Constitution (Kathmandu : UNDP

Nepal, 2008).

Health is Wealth, 9

Although scattered across Nepal, Dalits tend to reside in the Terai in higher numbers. In the

Terai region, eleven geographically heterogeneous caste groups, of whom Doms, Mushars, and

Chamars are the most disadvantaged, are subsumed under “Dalit”.16

As mentioned in Table 1,

landlessness among the Terai Dalits is prevalent, and most work as wage laborers. This

characteristic is significant since agriculture is the predominant occupation in the region,

indicating that landlessness is a risk factor for poverty in the Terai. By depriving Dalits of any

bargaining power, landlessness forces them to work as daily agricultural laborers at very low

wages and thus leads them into a pattern of ever increasing dependency on the landlords.17

Many

studies have highlighted this connection between low-caste status and low agricultural wages.18

Similarly, the informal credit markets limit economic opportunities for Dalits and other low-

status ethnic groups as they are driven by high interest rates established by higher castes. Thus,

in the rural parts of Terai, the economic hierarchy is largely determined by caste and ethnicity.

4.5 The Health Situation

Nepal’s overall health indicators are poor by international standards and are comparable to those

of other South Asian countries. According to the latest data available through the Nepal

Demographic and Health Survey of 2006, the infant mortality rate is 40 per 1000 live births,

while the maternal mortality ratio is 281 per 100,000 live births.19

Nepal also has high rates of

child malnutrition at 72 percent in 2001, and high levels of under-five mortality, with 91.2 deaths

per 1,000 live births in 2001.20

Sanitation and access to safe drinking water are limited,

particularly in rural areas. According to data available from the National Management

Information Project only 33 percent of people in rural Nepal had access to improved sanitation

facilities in 2008.21

Moreover, 21 percent of Nepali rural households do not have access to

improved drinking water sources and 95 percent of rural households do not have a functioning

water connection.22

Health care disparities in Nepal exist along several axes. As in the rest of South Asia, women in

Nepal suffer several disadvantages relating to health care but this fact is often missed by

conventional indicators. (Refer to Table 2 in Annex 1.)

16Y. Ghimireand S. Sharma (2002) 17M. Hatlebakk, Economic and social structure that may explain the recent conflicts in the Terai of Nepal (Bergen,

Norway: Chr. Michelsen Institute, 2007). Web. 18 December 2011.

<http://www.norway.org.np/NR/rdonlyres/0993F5660B3548A98F819167B4FD596C/72944/http___wwwcmi.pdf>. 18Ibid 19 Ministry of Health and Population Nepal, New ERA, and Macro International Incorporated, Nepal Demographic

and Healthy Survey 2006 (Kathmandu, Nepal: Ministry of Health and Population, 2007). Web. 18 December 2011.

<http://www.measuredhs.com/pubs/pdf/FR191/FR191.pdf>. 20 Ibid. 21 World Health Organization and United Nations Children’s Fund, “Joint Monitoring Programme for Water Supply

and Sanitation: Estimates for the use of Improved Drinking-Water Sources” (Nepal, 2010) Web. 18 December 2011.

<http://www.wssinfo.org/fileadmin/user_upload/resources/NPL_wat.pdf>. 22

Ibid.

Health is Wealth, 10

Similarly, health care indicators that appear to put Terai on par with the rest of Nepal hide

significant intra-regional health care disparities.23

Finally, health care status appears to have a

positive relationship with caste indicating that as one descends the caste ladder health indicators

also worsen. Health care disparities between Dalits and upper castes are examined through this

research.

4.6 Human Rights and Health Care Access for Dalits

“The right to health” was first reflected in the 1946 World Health Organization (WHO)

Constitution, reiterated in the 1978 Alma Ata Declaration, and finally adopted by the World

Health Assembly in 1998.24

The right to health is defined as the right to the highest attainable

standard of health, which is inclusive of a set of social indicators, norms, institutions, and laws.25

The most authoritative interpretation of this right is outlined by Article 12 of the International

Covenant on Economic, Social, and Cultural Rights (ICESCR).26

Including Nepal, 145 countries

have ratified the ICESCR.27

There are four criteria that measure the right to health: availability,

accessibility, acceptability, and quality. Many policy makers around the world frame health

policy as service delivery without consideration for the complexity of overlapping accessibility

issues. However, international standards indicate that it is unacceptable to pursue health care

with this “if you build it they will come” mentality.28

Accessibility as interpreted by the ICESCR is defined as follows: “Health facilities, goods and

services have to be accessible to everyone without discrimination, within the jurisdiction of the

State party.” This definition can be seen as capturing four dimensions of health care access: non-

discrimination, physical accessibility, economic accessibility (affordability), and information

accessibility.29

Out of these the most complicated dimension to measure is discrimination, as it

can be overt, passive, or institutionalized. Moreover, discrimination manifests itself in a variety

of complex often overlapping dimensions occurring at any point between policymaking and

actual health care delivery. This picture is further complicated by the fact that largely the

populations that most lack access to health care are also the populations that are the most

discriminated against with regards to such access.

Recently there has been a shift in development practices that emphasize a rights-based approach.

A rights-based approach to health applies a human rights framework to health care systems and

can be applied to “assessing and addressing the human rights implications of any health policy,

programme or legislation; making human rights an integral dimension of the design,

23G.C. P. Singh, M. N. Ruth, B. Grubesic and F. A. Connell,"Factors associated with underweight and stunting

among children in rural Terai of eastern Nepal", Asia Pacific Journal of Public Health, 21. 44 (2009). 24 World Health Organization,“25 Questions & Answers on Health & Human Rights”, Health & Human Rights: An

International Journal,1.9 (2002). Web. 22 Feb. 2012. <http://www.who.int/hhr/activities/en/25_questions_hhr.pdf>. 25Ibid 26Ibid 27Ibid 28L. London, “What is a human rights-based approach to health and does it matter”.Health and Human Rights: An

International Journal, 10.1 (2008). Web. 16 Feb. 2012.

<http://www.hhrjournal.org/index.php/hhr/article/viewArticle/25>. 29 World Health Organization (2002)


implementation, monitoring and evaluation of health-related politics and programmes in all

spheres, including political, economic and social.”30

One crucial element in this approach is the

identification of vulnerable groups in order to enable service delivery in a way that protects the

right to health for all individuals within the catchment area.

The protection of all individuals’ right to health is fundamental to accomplishing the highest

attainable standard of health. This approach has the potential for strengthening health systems

and empowering marginalized communities and increases social, economic and political

development, nationally as well as internationally, by increasing progress towards international

support in accomplishing the Millennium Development Goals (MDGs).31

“Framing access to

health care and the conditions for health as a matter of service delivery is a political choice that

demobilizes effective rights advocacy.”32

A human rights-based approach to health is best

facilitated by participatory approaches, which enable the most disadvantaged groups to voice

their health needs and priorities. 33

“This model is considerably different from those that frame

rights as simply standards for state conduct, since it moves away from notions of benevolent

handouts by state or third parties to ameliorate suffering of passive recipients of assistance.”34

This approach requires clear definitions of who is a rights holder and who is a duty bearer and

what the obligations of facilitation are for accountability purposes.35

These responsibilities

towards upholding a rights-based approach to health manifests at multiple levels with a variety of

stakeholders; however, these guidelines depend entirely on the capacity of institutional

frameworks of regulation within formal and informal health systems.36

Incorporating human

rights language into the health system and national health priorities strengthens the health

sector’s ability to protect the right to health for all; however, this is only operationalized if there

is a strict accountability framework and protocol with consequences for violators.

Save the Children in Nepal found that incorporating inclusion practices within service delivery

or programming “for all” was more effective and accepted than providing special provisions for

disadvantaged populations.37

Another mechanism that has been used to make health care more

inclusive of marginalized populations is the recruitment of practitioners from disadvantaged

communities – this demonstrates commitment by the state to mainstream inclusion policies and

practices.38

It is also equally important not to create parallel heath systems that reinforce societal

structured discrimination. If the health system caters towards a marginalized population while

separating their services from the general population, instead of including them the system will

end up reinforcing segregation and discriminatory practices.

30Ibid 31 World Health Organization (2002). 32 London (2008). 33 Daginfo, “Participatory Method for Mapping of Disadvantaged Groups (DAG) in DACAW.” Web. 22 Feb. 2012

<http://daginfo.deprosc.org.np/>. 34 London (2008). 35Ibid 36Ibid. 37N. Kabeer, “Social Exclusion and the MDGs: The Challenge of ‘Durable Inequalities’ in the Asian Context.” ,

Institute of Development Studies, 2006. Web 19 Feb. 2012.

<http://www.eldis.org/vfile/upload/1/document/0708/DOC21178.pdf>. 38Ibid


4.7 Dalits and Health Care Access

Dalits in Nepal experience a complex nexus of historical, societal, and institutionalized

discrimination. This discrimination has led to intergenerational poverty, which is an important

determinant of access to health care.39

“Discrimination against Dalits has metamorphosed over

time from overt, open and accepted norm to subtle, invisible, hidden and ‘unacceptable’

behavior”40

, yet it still occurs within multiple levels of the health care system. According to the

Nepal Human Development Report (NHDR) of 2001, Brahmins (an upper caste) had

significantly better infant mortality figures as compared to Dalits, 50 and 116 per 1,000 births

respectively.41

Malnutrition among children in Terai increases steadily as one descends in the

caste system from Brahmins to middle-castes to Dalits.42

Another example of caste-based

disparities in health care is provided by the figures on place of delivery in Table 3.

Table 3: Place of last delivery by caste/ethnicity: Dalits compared to National average,

Brahmin/Chhetri and Other Caste/ethnic Groups

Caste/Ethnicity

Brahmin/ Chhetri Dalit Total (including

communities not

included in this table)

Place of Birth

last child

N % N % N %

Hospital/Health

center

133 45.1 58 33.3 327 40.3

Private Nursing

Home

11 3.7 1 0.6 21 2.6

Home 149 50.5 112 64.4 454 56.0

Others 2 0.7 3 1.7 9 1.1

Source: Devkota , B.(2008)

Dalits reported 33.3 percent hospital-based births while Brahmin/Chhetri were 45.1 percent and

similarly Dalits reported home births 64.4 percent while the high caste had home births 50.5

percent of the time. The World Health Organization (WHO) emphasizes the importance of

institutionalized births as a mechanism of improving both maternal and infant mortality and is

often used as an indicator of better access to health facilities.43

It is clear from Table 3 that Dalits

with only 33.3 percent institutional deliveries are at greater risk of mortality and complications

while also alluding to decreased access to health facilities compared to Brahmins and Chhetris.

39S.S. Acharya, “Children, Social Exclusion and Development: Working Paper Series.”, Indian Institute of Dalit Studies, 2010. Web 18 Feb. 2012. <http://dalitstudies.org.in/wp/wps0102.pdf>. 40 Acharya (2010). 41 United Nations Development Programme, National Human Development Report 2001. Web. 18 December 2011.

<www.undp.org.np/publication/html/nhdr2001/NHDR2001.pdf>. 42G.C. P. Singh, M. N. Ruth, B. Grubesic and F. A. Connell (2009) 43World Health Organization, “Health Statistics and Health Information Systems” ,WHO, 2012. Web. 5 May 2012.

<http://www.who.int/healthinfo/statistics/indmaternalmortality/en/index.html>.


The State has not yet explicitly defined “marginalized communities,” and yet it is essential to

have an agreed upon formal definition of exclusion which clearly identifies specific groups and

categorizes them according to the degree of exclusion they have experienced.44

In India, Dalits

experience discrimination in access and utilization of health care at all points of service delivery

in health care facilities and during home visits by all levels of health care staff.45

One study

indicated that Dalits experienced discrimination in the following ways: untouchability during

examination and during the dispensing of medicine, interactions with health care workers

including the use of derogatory language, referrals, counseling, pathological testing, distance

traveled to points of service delivery, length of time waiting for care, and level of care including

if health care workers would enter homes of Dalits for care.46

“In brief, social exclusion reflects the multiple and overlapping nature of the disadvantages

experienced by certain groups and categories of the population, with social identity as the central

axis of their exclusion. It is thus a group or collective phenomenon rather than an individual

one.”47

Holding demographic characteristics such as assets and education constant, Dalits were

still 19 percent more likely to be poorer than the rest of the population.”48

44 Thapa (2009) 45 Acharya (2010) 46 Acharya (2010) 47 Kabeer (2006) 48 Kabeer (2006)


4.8 Millennium Development Goals

In recent years, there have been criticisms of the Millennium Development Goals (MDGs) and

their linear model of monitoring and evaluating progress within countries. As Freedman notes,

“…Strategies for meeting the MDGs should be premised on an understanding of health systems

as core social institutions that help define the very experience of poverty and citizenship.”49

This

understanding reveals health inequities in health care systems and the widening gap between the

wealthy and the poor.50

Standing indicates that “there is an equally important discourse of rights as situated in experience

and gained and maintained through empowerment and struggle: that is, rights from below.”51

Freedman supports this saying, “Peoples’ interactions with that system, thus defines in critical

ways their experience of the state and of their place in the broader society.”52

When access to

health care depends on the ability to mobilize assets, resources, and networks, it effectively

excludes the most marginalized populations.53

“Thus, in the context of Nepal, in order to bring

out the true picture of each MDG goal and target, data need to be disaggregated by sex in

totality, as well as further disaggregated by sex in relation to different caste, ethnicity and sub

national groups. Otherwise, while the MDGs target would be met at the national level, a large

section of the excluded population shall still remain deprived.”54

4.9 Nepal Public Health Sector

A landlocked country in South Asia, Nepal is administratively divided into 75 districts. The

districts are also regrouped into 14 zones, which are then regrouped into five development

regions along geographic distinctions (Eastern, Central, Western, Mid-Western, and Far-

Western). Administrative districts are broken into smaller administrative units consisting of

municipalities and Village Development Committees (VDC), which are also regrouped into

Electoral Constituencies. Each VDC is generally composed of approximately 500-700

households.55

The Nepali health system is broken down in a way closely resembling the

administrative breakdown of the state, as can be seen in Figure 1.

49L.P. Freedman, “Achieving the MDGs: Health systems as core social institutions.” Web 14 Feb. 2012.

<http://ipsnews.net/indepth/MDGGoal5/MDG5%20Freedman.pdf>. 50Ibid 51 H. Standing, “Understanding the 'demand side' in service delivery: definitions, frameworks and tools from the

health sector.”, DFID Health systems Resource Centre, 2004. 15 Web. 24 Feb. 2012.

<http://www.youthnet.org.hk/adh/4_4Sframework/3_Services_n_commodities/3_Families%20and%20community/

Demand%20Creation.pdf>. 52 Freedman (2012) 53Ibid 54 Thapa (2009) 55S.K. Rai , G. Rai, K. Hiraji , A. Abe and Y. Ohno, “The Health System in Nepal – An Introduction”.

Environmental Health and Preventive Medicine. 6 (2001) 1-8.


Figure 1 - Organization Chart of Department of Health Services, Nepal56

56 Fielden, R. Assessment of the Health System in Nepal with a Special Focus on Immunization for UNICEF. 2001.

Web. 23 February 2012. <http://www.unicef.org/evaldatabase/files/NEP_00-019.pdf>.


The Ministry of Health oversees the entire health structure through its Department of Health

Services. Tertiary care is delivered at the Central and Regional Hospitals, whereas secondary

level of care is delivered at the Zonal and District Hospitals. Primary health care is delivered at

the VDC and Electoral Constituency levels through Primary Health Centers (PHC) and Health

Centers (HC), Health Posts (HP) and Sub-Health Posts (SHP). Further outreach into the

community and health care delivery is conducted through various outreach entities, including

Female Community Health Volunteers (FCHVs), Traditional Birth Attendants (TBAs), PHC

outreach and EPI (Expanded Program on Immunization) campaigns and clinics. Overseen by the

District Health Office (DHO), the PHC/HC, HP and SHP are of particular importance in rural

areas, forming the basic and most accessible units of health care in these communities. Likewise,

the various community health workers and campaigns are equally important, serving as their

direct extensions into remote areas. These primary health care delivery points embody primary

tenets of recent health care policies developed in the country, specifically the elements of

decentralization and provision of Essential Health Care Services (EHCS). The FCHVs serve as

the communities’ first point of contact with the health care system, promoting health, healthy

behavior and providing basic health services with the support of SHPs, HPs and PHCCs

Throughout the health structure, there are 15 regional and zonal hospitals. At the regional level

there are also Regional Training Centers, laboratories, TB centers and medical stores. On the

local level there are 296 Primary Health Care Centers, 676 health posts and 3,134 sub-health

posts in the country.

4.10 Non-State Health Sector

An extensive non-state health sector exists parallel to the government/public health sector. This

parallel system is heavily utilized by citizens. The 2003-2004 NLSS reported that 40 percent of

those seeking treatment for acute illness visited private pharmacies and 9 percent went to private

hospitals, while only 44 percent sought care in government facilities.57

The non-state health sector is divided between both for-profit and not-for-profit entities. The

Government of Nepal seeks to support and collaborate with non-state actors and utilizes this

network as the service provision arm of the formal health system in order to allocate government

resources to management, finances, and policy. Apart from being involved with private

pharmacies, which often provide examinations along with dispensing medications, the for-profit

sector is involved in medical education, training, and health laboratories. The non-state not-for-

profit sector consists of NGOs, INGOs, civil society and community-based organizations.

The use of Ayurveda, a tradition of medicine indigenous to South Asia, is still quite widespread

in Nepal with the government trying to institutionalize this system by founding a Department of

Ayurveda under the Ministry of Health (parallel to the Division of Health Services and Drug

Administration). In addition, traditional healers are often utilized at the community level,

complementing this more formalized branch of alternative medical care.

57Central Board of Statistics, Nepal Living Standards Survey 2003/04 (Kathmandu: G. o. N. Planning Commission

Secretariat, 2005).


4.11 Health Policy Overview

Nepal consists of a fairly comprehensive framework of health policies, plans, and strategies.

Although, the first policy directly relating to health was not drafted till the 1990s, the

Government of Nepal has created several five-year plans since the 1950s. The first eight plans

have focused on different aspects of development, such as employment, infrastructure, and

economic stability.

With increased participation in international bodies and mobilization of External Development

Partners (EDP) within the country, Nepal has shifted its national policies to accommodate

internationally agreed agendas. In 1978, at the International Conference on Primary Health Care

co-sponsored by UNICEF and WHO, Nepal re-affirmed its commitment to providing the Nepali

people “a level of health that will permit them to lead a socially and economically productive

life.”58

Through this conference and the declaration of Alma-Ata, it was stressed by the world

community that the key to realizing this goal by 2000 was to focus on investing, implementing,

and supporting the PHC through technical and financial means. This was a part of the “Health

with All” agenda that aimed to bring “health” for all people because health was seen as a human

right and it was the responsibility of all humanity to realize this common goal.

As one of the consequences of this paradigm shift in development and human rights, the first

Nepali national policy directly related to health was passed in 1991. The aim of the National

Health Policy (1991) was to expand the primary health care system to the rural. It focused on

service delivery within the administrative structures of the health care system. In 1992, the

Eighth 5-year plan also reflected the impact of health in the development of Nepal. The Eighth

Plan (1992-1997) focused on population policies primarily on family planning and programs

while the Ninth 5-year plan (1997-2002) centered around poverty alleviation through

improvements in education that were all cross-cutting to the issue of health and development.

In 1997, the Ministry of Health created the Second Long Term Health Plan (SLTHP) (1997-

2017). The SLTHP aimed to close the disparities in health care by outlining 15 health targets for

the country as a whole. It assured the people of Nepal access to quality health care services by

gender sensitization and equitable community access. The plan’s long-term vision is to provide

health care with equitable access and quality in both rural and urban areas. It targets the most

vulnerable and under-privileged groups such as women and children, the rural, and the

marginalized by promoting access to the low-cost high-impact EHCS.59

There are 20 components

to the EHCS package, ranging from promoting primary health care at the community level to

strengthening partnerships with international NGOs.

Since its introduction in 1997 the SLTHP has been complemented by a number of

implementation plans. In 2003, the “Health Sector Strategy: An Agenda for Reform” was

prepared and approved by the Council of Ministers as a response to the analytical works

58M. Ono, “From ‘Health for All’ to ‘Health with All’ in Nepal- Through Empowered Civil Society as Rights and

Responsibilities of All Humanity”, 2001. Web. 19 February 2012.

<http://www.hsph.harvard.edu/research/takemi/files/RP183.pdf>. 59 World Health Organization Country Office for Nepal, “Health System in Nepal: Challenges and Strategic

Options” . 2007. Web. 19 February 2012 <http://www.nep.searo.who.int/LinkFiles/Health_Information_HSC.pdf>.


undertaken by EDPs during the last few years. The analysis of the frameworks and plans done

throughout the last few years had revealed that the MoH should focus on health problems, which

were disproportionately affecting the population. Reviews also called for the development of a

common strategy where all interested parties could collaborate in contributing to better health

outcomes in Nepal. Following this agenda, the first Nepal Health Sector Program-

Implementation Plan (NHSP-IP) (2004-2010) was formulated in 2004. This plan took a multi-

stakeholder, sector-wide approach that aimed to improve health care in Nepal by prioritizing

eight outputs: 1) improvement of EHCS, 2) decentralized management of health facilities, 3)

partnerships between public and private sectors, 4) strengthening of sector management, 5)

financing and resource allocation, 6) improved management of physical assets, 7) human

resource development, and 8) integration of a management information system and quality

assurance policies.60

Within these outputs, the targeted indicators were linked with the

achievement of the MDGs framework. In 2010 this plan was replaced by Nepal Health Sector

Program-Implementation Plan II (NHSP-II), which introduced some crucial modifications while

carrying forward the basic thrust of its predecessor. The NHSP-IP II, which shall be in effect

until 2015, can be seen as addressing four aspects of health care access.

It aims to address matters of financial access to health care by aiming to universalize the EHCS

program to all levels below the district hospital. This includes the provision of free health care

services, both preventive and curative, for all Nepali citizens at SHCs, HCs, and PHCs. In

addition, a range of common medical investigative procedures for diseases such as TB and

Malaria among others, are supposed to be free of charge. Although this scheme provides for a

nominal service charge at district hospitals and above, this fee can be waived for members

belonging to ‘marginalized communities’ on presentation of adequate documentation. The plan

also provides for 40 free medications at the district hospitals and 32 free medications at all levels

below it.

It tries to aims to improve physical accessibility, especially for mothers, by offering a range of

pregnancy-related incentives. More precisely, a sum of NPR 100 is to be provided for each of the

four prescribed antenatal checkups (ANC), while a lump sum of NPR 500 is provided for all

institutionalized deliveries. In addition to these, financial incentives are also provided to offset

the costs of transportation.

Matters of informational access are addressed on two levels. First, it provides for the institution

of Information Education and Communication (IEC) programmes to improve the health behavior

of the poor and excluded. The second measure is more indirect and has to do with an increase in

the total number of FCHVs in the country by 5000. The health care system of Nepal relies

primarily on the Female Community Health Volunteers for the task of increasing health care

related awareness within the community. These FCHVs are tasked with providing community

members information regarding free health care services available at the local level, informing

them about the symptoms of common diseases, and advising them in cases which require referral

to higher centers. The specific areas that require an increase in numbers shall be decided by the

District Development Committee (DDC) with the help of input provided by the various VDCs.61

60 United Nations Nepal Information Platform, Nepal Health Sector Programme- Implementation Plan (NHSP-IP)

2004. web. 19 February 2012. <http://www.un.org.np/node/10321>. 61 Ibid


NHSP-IP II also explicitly acknowledges the need to specifically target ‘marginalized’

communities. This approach is taken even more seriously by the Gender Equality and Social

Inclusion (GESI) Strategy, which is one of the milestones recently approved by the Ministry to

reduce cultural and financial barriers to health services for women and children, Dalits, Adibasi

Janajatis, Muslims, Madhesis, and other disadvantaged groups. A collaborative effort between

three international development partners (Asian Development Bank, UK-DFID, and the World

Bank), GESI is particularly relevant in the context of Nepal as there is significant overlap

between gender, caste, and ethnicity-based exclusions in the country, which are further cut across

various hierarchies, sectors, institutions, religions, and languages. This strategy has the following

three stated objectives:

1) Focuses on developing policy, plans, and programmes that mainstream GESI in Nepal’s

health sector by ensuring the inclusion of the GESI framework in Nepal’s development

policies and strategies, both at the central as well as local levels;

2) Aims to “enhance the capacity of service providers and ensure equal access and equitable

use of health services by the poor and excluded castes and ethnic groups in regard to a

rights-based approach.”62

This will be accomplished by making service providers

accountable for the equitable delivery of EHCS to marginalized populations, by

identifying target groups in excluded populations, and by making existing service

delivery sensitive to the needs of women and socially excluded groups; and

3) Seeks to improve health behavior of poor and excluded groups through a rights-based

approach.

Taken together, these goals reflect a growing concern on the part of the Ministry of Health to

ensure discrimination-free health care delivery to all groups.

62 United Nations Population Fund, Nepal Health Sector Programme-Implementation Plan II (NHSP-IP 2) Web. 18

February 2012. <http://www.unfpa.org/sowmy/resources/docs/library/R090_MOHNepal_2010_NHSP-IP

II_Final_Apr2010.pdf>.


V. Objectives

In collaboration with Samata Foundation, the Columbia University team sought to achieve the

following objectives through this project:

(1) Research existing health policies and structures in Nepal;

(2) Collect data on the health care experiences of Dalits and non-Dalits in several

communities in Saptari District (in the Terai region of Nepal);

(3) Investigate and assess Dalits’ access to health care using five dimensions of “access”

(information access, physical access, financial access, discrimination and social capital);

(4) Provide next step and policy recommendations for Samata Foundation to pursue in

advancing Dalits’ access to health care and right to health;

(5) Provide Samata Foundation with an actionable strategy; and

(6) Help inform the Gender Equality and Social Inclusion (GESI) team’s plans for a national

study on health care accessibility for Nepal’s marginalized populations by sharing key

findings and tools.


VI. Methodology

This research aims to examine health care access for Dalits in Nepal through the experiences of

stakeholders throughout the health care system. The primary objective of this research is to

identify health care policies and practices which contribute to the basic health status of the Dalit

community in the Terai region (Southeast Nepal) and to make recommendations on how to

improve health policies and implementation practices to be more inclusive of Dalits. This

research utilized ethnographic research methodologies while employing a participatory approach.

The research questions and approach were informed by an extensive literature review. This

literature review highlighted four dimensions of access, which were utilized throughout the

research.63

Concluding the first field visit a fifth dimension was uncovered and incorporated into

the research. The five access dimensions, which informed the research, included financial

accessibility, information access, discrimination, physical accessibility and social capital. All

five of these dimensions informed the research questions, the research approach, and finally the

analysis.

Several tools that were developed in the first field visit that informed the investigative approach

for the duration of the research included a stakeholder analysis and an institutional analysis. Both

of these tools provided insight as to the power dynamics, politics, norms and decision making

processes that influence health care access or delivery of health care services to both the general

population and marginalized communities.

Several participatory research tools were employed throughout the research including key

informant interviews (KI), focus group discussions (FGD), and participatory ranking

methodology.64

The KI interviews were used to include perspectives of individuals working

within the health care system such as health care providers and both low and high-level policy

makers. KI interviews were used to obtain more details into a topic that may have only been

highlighted in FGD with beneficiaries.65

FGD were conducted in two parts. The first activity conducted during a focus group discussion

included participatory ranking methodology. During this activity, participants highlighted the

main health care issues that caused them to seek health care. Participants defined these issues,

provided explanations and then they ranked them according to importance. The second activity

built off of the first activity in which participants examined the health care issue that was ranked

as the most important issue and a discussion was facilitated in which participants identified care

responses to that issue. Participants would narrate what a family would do if a family member

were affected by this issue inclusive of health seeking behaviors, decision-making processes,

consequences, assets and problems or barriers during this process.66

All health seeking behaviors

and consequences in response to this very important health issue were identified and discussed.

63 World Health Organization (2002). 64 The research methodologies will be shared with the Gender Equity and Social Inclusion team to inform for a national study on health care accessibility for Nepal’s marginalized populations by sharing key findings and research

methodologies. This information was requested during a ‘preliminary findings’ meeting held at Samata Foundation

concluding the final field visit. Additional technical support will be provided to the GESI team upon request. 65 Please refer to Annex 2 for the semi-structure interview guides that were utilized during key informant interviews. 66 Please refer to Annex 2 with the semi-structure interview guide that was used for focus group discussions.


For all stages of the ethnographic research, interviewers interacted with a diverse cross section of

the community and the health care sector. Participants were selected based on a two-stage

convenience sampling and with consideration to sampling a variety of levels within the health

care system including beneficiaries. Communities were selected based on a matching approach.67

In order to have an appropriate number of participants within each FGD, communities were

matched based on three strata criteria. Communities were matched based on demographics such

as high and low population levels of Dalits, FGDs were then disaggregated based on gender and

caste. A minimum of four FGDs were held in each community, one set with non-Dalits (both

male and female), and one set with Dalits (male and female). Each community was then matched

with another community based a community assessment of the high-low demographic of Dalit

populations. This matching approach improved the team’s ability to isolate incidences and relate

associations to similar demographics, gender, location or caste thereby strengthening the final

analysis. This process ensured that no one group or demographic biased our results.

67 Please refer to Annex 4 for a map of the communities that were selected and the number of KI interviews and

FGDs that were conducted in each.


VII. Limitations

The desk review was limited by the lack of detailed information on the Terai and the Saptari

district. These limitations were exacerbated due to language constraints as most of the

documented material was in Nepali and not in English. The scope of this project was limited by

logistical constraints of time and geographical accessibility to Saptari. The combination of these

two constraints resulted in the research focusing the data collection to one district in which

Samata could facilitate access. The greatest single limitation was the amount of data collection

that could be accomplished in a total of 4 weeks in the field. The research team prepared for this

constraint in advance; however, it still narrowed the research focus and scope.

Field visits were both facilitated and limited by individual relationships held by the field

coordinator who guided the data collection and community selection for participation. Without

the assistance of a field coordinator the research team would not have had access to particular

communities or populations for data collection; however, those same networks that were utilized

by definition implies there were some communities or populations that may have been excluded

from data collection due to a lack of knowledge or social relationships. Despite social networks

and general accessibility to communities the research team was able to access both urban and

rural settings as well as Dalit and non-Dalit communities. The research methodology was

constrained by the ability of the research team, field staff and assistance from community

discussion to match communities based on similar demographics. This constraint was

exacerbated by lack of up-to-date data on population figures by the VDC and the lack of

population data disaggregated by caste. The research team therefore relied on local reports and

perceptions of concentrations of Dalits in VDCs across Saptari, and as such the matching of

demographics was based on informal traditional knowledge.

Translation presented many major limitations, as translators were required for all focus group

discussions and many interviews. The research team mitigated some difficulties with translation

by discussing the planned methodology and approach in advance while emphasizing the role and

expectations of the translation. Despite clear understanding of the methodologies, approaches,

roles and expectations due to the very nature of translation, it was difficult to measure the degree

of accuracy to which the questions are asked and the responses are translated. Cultural

differences and nuances may have affected the questions being asked, in particular the

terminology used, and the responses received. Inquiries regarding caste often warranted

precaution and cultural sensitivity in the translation and directness of language used during

interviews and focus group discussions. This indirect use of language by the translators may

have diverted the discussion away from the original question and perhaps influencing the results

captured in our data collection.

Being aware of this dynamic, the research team carefully adapted the data collection technique to

account for this more appropriate method of approaching the issue. Local understanding and

indirect translations may have also influenced participant responses received to questions of

important diseases and their ranking during activities of participatory ranking. What constitutes

an “important” disease varied from group to group and in general groups were unfamiliar with

the ranking process. For these reasons, the most important illnesses ranking should be considered

carefully with these limitations in mind.


In addition, the research team utilized the services of two translators. Each translator had varying

levels of experience and differing styles of translation thereby influencing the quality of data

captured. In some cases translations required a three-way translation between English, Nepali

and Maithili also influencing the level of quality of the translation. These differences among the

translators may skew comparability. The research team also captured information using both

audio recordings and hand written notes these two mechanisms facilitated the transcription

process. Few audio recordings were limited by the quality of the audio recording for which the

research team relied on notes from the field. This adaption may have also influenced the quality

of the transcription.


VIII. Key Findings

8.1 Structure

When analyzing Nepal’s health care structure, access to health care proved to be a concern for

both Dalit and Non-Dalit populations due to its weak structure and limited capabilities. The

analysis revealed that a lack of resources, absence of a monitoring mechanism for different levels

of health care and problems with decentralization were the main causes of a weak Nepali health

system.

In all levels of care, the lack of resources was evident based on interactions with both

beneficiaries and providers. Medicines, supplies, equipment and skilled health attendants were

short in supply at hospitals, posts and centers throughout the district. A Dalit woman from

Joginya explained that the PHCs“[don’t have] the medicines, they don’t have the skills. And they

don’t have the government-provided medicines. They only provide saline water and give the slip

to buy those things outside.” Patients are required to purchase supplies at private clinics,

pharmacies and shops because the local health centers do not have the capacity to provide them.

A non-Dalit male from Chinnamasta further described the lack of resources, not just in material

supply but also in personnel:

“There are six districts and only one zonal hospital in the region.

The hospital is [very dirty]. Doctors don’t come on time;

sometimes they don’t come at all. Doctors have their own private

clinic, where they spend more time. The treatment is

unsatisfactory. The hospital is not well equipped. Even for small

diseases they refer to Dharan or Biratngar. Especially brain

related problems, they refer to India.”

The shortage of resources is a systemic problem throughout the health care structure. However,

both providers and beneficiaries have an assumption that the higher levels of care include more

skilled personnel and resources available. This assumption contributes to a “Ping-Pong” effect,

where providers often refer patients to other forms of care within the structure, usually a higher-

level care from the referee’s. Though patients are referred to higher levels of care, it is not

guaranteed that they receive adequate care or resources at these higher levels, subsequently

burdening the patients by prolonging an adequate diagnosis and increasing financial constraints

such as additional costs including transport fees.

The absence of a strong mechanism of checks and balances for different levels of health care is

alarming. Findings revealed several accounts of corruption, mismanagement, and abuse of

authority in some hospitals, posts, and centers. The lack of a functional monitoring and reporting

system with strong disciplinary measures for reprimanding ill-performing health professionals is

crucial for the transparency and accountability of the health care system.


Though policy indicates that Nepal’s health service delivery is a decentralized structure, the

findings from the field reveal that this decentralized method is not effectively implemented. The

mandates of health care personnel in all levels are highly centralized at the core, and the delivery

of resources to the lower levels remain varied according to each health post and the capacity of

its chain in command. The failure to provide health care services with a decentralized model

creates a perception of mistrust from the beneficiaries to the providers of the health care system.

8.2 Perceptions

The findings of this research highlight how the system is perceived by health care providers and

officials working within it, while also capturing the perceptions of beneficiaries.

Health care Providers and Officials

A rather surprising finding that emerged from interviews with higher officials and bureaucrats

was that they characteristically tended to lay the blame for the existing health care disparities on

the communities themselves. While referring to the Dom community, a top-level bureaucrat in

the health ministry stated the following: “if some communities do not like to utilize health

services, no government health officials can do anything. We can only educate them. If they

themselves refuse, we cannot do anything” We also frequently encountered biases regarding

certain populations among these officials, with women and Dalits often being described as

possessing “low capacity.”

When asked about their perceptions of the health system itself, the responses of health care

providers and officials varied according to their place within the hierarchy. A recurrent pattern

that emerged from interviews was that higher officials tended to take an optimistic view of the

quality of work of their subordinates, for whom they were indirectly responsible. For instance,

when asked about the estimated number of health centers working well a high level official

reported “more than 80 percent of sub-health posts and more than 85 percent of health posts are

doing well. Almost 100 percent [of] PHCs are doing great.” At the same time, however, lower

officials tended to view the levels above them as characteristically opaque and corrupt. The

above official when asked about his superiors had the following to say: “there should be

improvement but we cannot intervene. They can do everything. They can also take back

everything. It is a problem of decentralization. All the power rests with the ministry of health.

They are the bosses.” Similarly, an Assistant Health Worker (AHW) in referring to his superiors

told us that “…all the officials sitting at the District level are thieves.”

Such perceptions towards superiors were often accompanied by a perceived lack of

accountability within the system. A Health Assistant at a Primary Health Center (PHC) reported

that the doctor who was officially posted at the center had not shown up for six months. When

asked about the steps he had taken to correct the situation, he explained that, “we have been

trying to convince the doctor to come here, but she makes a lot of excuses…apart from trying to

convince her, we are powerless” From the perspective of lower level health care workers, the

Nepali health care system emerges as corrupt and unaccountable. With little capacity for actual

decision-making, lower level officials and health care providers moreover appear to have no

significant stake in the proper functioning of the system.


Beneficiaries

The predominant perception of the health care system among the Dalit population of Saptari is

reflected in the fact that Dalits, who traveled long distances from their villages to government

hospitals in big cities, frequently required assistance, both in completing the complicated

documentation process, as well as pressuring health care staff to provide services that were

expected to be free of charge. One Dalit had reported advocating on behalf of other Dalits in a

government hospital, explaining that “… (we) try to push to get it (services) for free or for half

price,… it’s not the hospital’s cost, it’s the government’s cost but still the administrators don’t

want to give these free services” In contrast, non-Dalits tended to be relatively better informed

about the workings of the health care system but commonly looked upon it as corrupt.

8.3 Information Access

Dalits do not have adequate information or knowledge of the causes and cures of diseases; the

symptoms are often mistaken for causes. In contrast, Non-Dalits tend to have more knowledge of

chronic diseases and can identify their presence at early stages. It is common for Dalits to not be

well informed of the health care services that should be made available by the government

system, which limits their ability to access the system in the correct way and to demand services

from the system.

Generally, both Dalits and non-Dalits lack awareness of medicines and incentives made available

by the health system. Of the 32 medicines listed as free by the official government policy, Dalits

tend to receive between 2 and 5 of them while non-Dalits only marginally more. Incentives

provided for delivery in a government facility are known by non-Dalits and some Dalits, though

many Dalits are not aware of the system of incentives for antenatal care checkups.

This quote from a Dalit woman in Chinnamasta exemplifies the confusion and lack of knowledge

around medicines and incentives:

“We go for check-ups but we don’t get any money. We don’t know

about any incentives. We get the [antenatal care incentive] cards,

but we don’t know what they are for, or how it works. We don’t

know what’s supposed to be free, but we know when medicines are

supplied because we see it arrive in the car… We know about the

500 rupees [incentive for birth in a government health center] but

the hospital is closed… We don’t know about post-natal check-ups

or incentives…”

Sources of information for both Dalits and non-Dalits include primarily doctors, community

members, and family. The community often convenes to share advice on the health care avenues

that should be pursued in emergency cases, with Dalits regularly turning to more knowledgeable

non-Dalit community members. The media, including radio and in some cases newspapers and

TV in urban areas, in addition to in-person announcements, is an effective way of

communicating available government services and upcoming programs. FCHVs are also

mandated with the task of providing information on both services and prevention, and while


policy officials perceive this as an effective channel of communication, FCHVs report a lack of

training and therefore inadequate knowledge themselves. Dalits reported that there is not an

educational component to the role of the FCHV outside of the provision of polio drops and

occasionally family planning. One successful example of information sharing encountered in a

community is a women’s forum of both Dalits and non-Dalits that discusses the causes and cures

of medical concerns that commonly affect women and advises the community on related issues.

8.4 Physical Access

Several key themes emerged under the dimension of physical access. A more comprehensive

definition of “physical access” was used to assess statements, looking not only at the proximity

of facilities and services, but also at what was physically available and utilized by the

communities visited.

Proximity

Not uncommon in rural areas, distance and available facilities were cited as a challenge for

accessing care by both Dalits and non-Dalits in all villages visited. Likewise, both Dalits and

non-Dalits stated that the roads were poor and there was a need for better transportation in order

to improve access to health care. Tellingly, several stakeholders and community members

mentioned the importance of proximity to highways as automatically advantaging individuals

towards better access to care. A high-level health official recognized this by stating that “near

the highway it [health services] is better, near the border it is worse” supporting the observation

that remote communities had greater difficulty accessing care. The most extreme of the observed

communities was the village of Malhaniya, where FGD participants highlighted physical

isolation because of being surrounded by rivers- making it particularly difficult to reach facilities

outside the village, especially when there are floods.

Modes of Transportation

In discussing their ability to reach health care, FGD participants would also mention what mode

of transport they utilized to get health facilities. Both Dalits and non-Dalits acknowledged that

access to transportation varied between the two groups. When asked how he gets to the zonal

hospital, a non-Dalit man in Chinnamasta responded that with public transportation “it takes half

an hour, but poor people, usually Dalits, walk to save money” As indicated by this statement, it

was found that non-Dalits accessed facilities utilizing buses, ambulances, and cars more

frequently, while Dalits, citing high costs of transport and lack of ambulances, would often walk.

This, of course, impacts their ability to reach care in a timely fashion.

Levels of Care

Discussions revealed that higher levels of health care (such as zonal PHCs and zonal hospitals)

offered better services and had greater capacity. These institutions also offered more services

than lower-level facilities, and were better equipped to handle more complex diseases and health

issues.


There was a notable distinction between Dalits and non-Dalits in this realm as well. The data

revealed that non-Dalits bypass lower levels of care and almost always go directly to zonal and

district hospitals. By contrast, in describing their trajectory of seeking care, Dalits would almost

always first go to the lower health centers (going to either Sub-Health Posts or Health Posts)

before ultimately being referred to higher-level facilities to get the care they needed. Given their

increased interaction with community-based care, it is not surprising that Dalits also reported

having more interaction with FCHVs than non-Dalits did. Though admittedly non-Dalits had less

interaction with community-based health care providers, there was also a difference between the

two groups in terms of how they each interacted with these actors. Specifically, non-Dalits often

specified that doctors and FCHVs entered their homes when providing care, whereas there were

mixed reports of this happening among Dalits.

Financial Implications

All modes of transportation were associated with financial costs. Often possessing more financial

resources than Dalits, non-Dalits were better able to access faster modes of transportation (such

as buses and ambulances) when trying to get to health facilities. Dalits, however, stated that

utilizing these modes of transport posed a greater financial burden, which in turn influenced how

they got to health facilities. Apart from delaying access to care given their chosen mode of

transport, these financial implications also postponed Dalits’ seeking care at higher level

facilities to a later point in time- further delaying their utilization and receipt of the care they

sought.

8.5 Financial Access

Financial accessibility is an access dimension that was central in linking numerous barriers to

health care services and greatly influenced health-seeking behaviours. Overall both Dalits and

non-Dalits reported financial barriers to health care access; however, Dalits were more

disadvantaged than non-Dalits due to a variety of reasons highlighted in the areas of financial

incentives, barriers, and coping strategies.

Overview

According to the participants in our sample, non-Dalits reported using higher-level health

facilities such as the zonal hospitals or private health facilities 63 percent more often than Dalits.

Dalits inversely used lower level health facilities such as PHCs and health posts 66 percent more

often than non-Dalits. Non-Dalits on average reported not paying for health services including

health tests and medication more often than Dalits. Non-Dalits cited FCHVs with both positive

and negative experiences and utilizing India’s health care system, requiring the financial ability

to do so. Dalits cited issues of financial discrimination, fragmented financial incentives including

difficulty with administrative processes and financial hardship due to referral processes. The

following three sections will unpack some of these findings in more detail.


Incentives

Both non-Dalits and Dalits typically received 500 rupees for institutionalized deliveries.

However, non-Dalits typically received the 400 rupees for four consecutive antenatal check-ups

while Dalits rarely reported knowing about this or receiving this incentive. One FCHV noted that

“500 rupees are transportation costs, persons must be active, communities must be active, [the

FCHVs] inform [communities] about the card and other things …but they are not active.” This

quote captures a tension that was noted in many focus group discussions as an explanation for

why some individuals were not receiving some incentives while others were; however, it is

important to highlight that 70 percent of Dalits reported not receiving this service while 70

percent of non-Dalits reported having received it. One Dalit woman discussed this difficulty by

explaining, “We go for check-ups but we don’t get any money. We don’t know about any

incentives. We give, the cards, but we don’t know what they are for or how it works.”

Another tension that was mentioned particularly from the Dalit perspective was the inadequacy

of the 500 rupees, considering that additional financial barriers must be overcome in order to

seek health care. One Dalit man echoed what many claimed, saying, “It’s not enough… that the

transportation is not enough. For deliveries [we] spend about 3000 Nepali rupees. So [we] have

to buy everything, gloves, saline water, blades.” Dalits explained that on occasion they would

not receive the 500 rupees for an institutional delivery because they were in addition charged for

all of the materials for the delivery such as the birthing kits and medication, thereby reducing or

eliminating the principle incentive. Dalits reported paying for additional health services such as

medication and materials 66 percent of the time while more non-Dalits reported not having to

pay for those items. Non-Dalits also cited the use of blood tests and vaccinations while Dalits did

not mention those health services implying a higher level of care obtained by non-Dalits.

Barriers

Both Dalits and non-Dalits reported that a major barrier to health care services were health care-

associated expenses. Non-Dalits reported high expenses for services; however, typically in

reference to utilizing private clinics and with minimal use of the lower level health facilities.

Non-Dalits also reported quality of care as a deterrent of care or an underlying factor in their

decision-making processes in terms of what kind of facility they would pursue. Non-Dalits

reported that ambulance expenses were too high. Other associated health care costs were high

but one non-Dalit woman noted “two three times, groups of women had to pressure the PHC in

the past. Most people don’t know that you get free medicines there.” While Dalits comparatively

highlight “people who can talk and act smart can get [medicines] for free and people who can’t

[don’t get it for free].” Dalits reported three times more often than non-Dalits that medications

and additional services such as tests and vaccinations were too expensive required payment.

Dalits reported that they experienced additional barriers that were not highlighted with non-Dalit

focus group discussions such as financial discrimination, loans, and lack of information

regarding financial incentives and failed incentives. On Dalit man explained that “approximately

if 100 Dalits come in one month for check up only 10-12 people will get services for free.” Other

Dalits noted that social status influenced the incentives that they received and that they

experienced a reduction in discrimination due to their status within the Dalit community. One

Dalit man explained:


“[Health care providers] don’t give [Dalits] medicine. You ask 10

times but you still don’t get it. [Health care providers] don’t give

it. Even the free medicines… because the doctors and health

workers, because he’s more well known of a Dalit, for him they’ll

consider it and give him the medicine [because he is well known in

the community they give him free medicines], but for other Dalits

who don’t have a social position, they’ll mistreat [them] and give

[them] medicines late.”

Both Dalits and non-Dalits highlighted this link between health and financial assets. A non-Dalit

woman summarized this tension by stating, “Those who have the money go for the treatment,

those who don’t – they die.” One coping mechanism that is discussed in the next section is loans

for health care. Many Dalits also consider these loans a barrier, as the interest rates are very high.

One Dalit man recounted, “no one gives us loans without interest. There are only high interest

loans here, 3-7%...serious [illnesses] 7% interest, otherwise 3-4%. All poor people’s diseases

are serious, emergency cases.” The interest from these loans plagued Dalit families for years to

pay off if ever and they had lasting effects on families as they had to sell assets such as land or

became indentured servants to repay them typically to non-Dalit lenders.

Coping

Coping mechanisms to mitigate the effects of financial barriers primarily fell under the category

of loans for both Dalits and non-Dalits. Loans were the most reported coping mechanism for

both Dalits and non-Dalits; however, the origin and terms of those loans varied according to

affiliation. Non-Dalits reported using their family, friends and neighbours as financial supports in

emergencies. Typically these loans had little to no interest. Similarly, Dalits reported that they

use loans as a coping mechanism for financial barriers; however, one Dalit woman reported

“sometimes when there is a very serious case, the Dalits come together and go to a non-Dalit to

get some loan…if we don’t take loans, we shall die.” This quote is an example that Dalits

reported taking loans primarily from non-Dalits as they lacked social supports that could provide

financial assistance. Dalits also reported using microcredit and community savings groups more

often than non-Dalits.

Non-Dalits also reported changing health care facilities as a coping mechanism typically as a

way to pursue high quality health care as one non-Dalit woman noted, “Good treatment is the

first consideration. Money is secondary matter.” Non-Dalits also reported using lower level

health facilities such as PHCs and health posts for minor health issues as services were free and

easily accessible. Dalits were reported to change their service delivery points to traditional

healers again with dual purposes of improved quality of care – in the event that a government

facility did not cure their aliment or because of proximity, they were located in the community

and therefore would save transportation expenses. One Dalit man explained that “they try to go

to Rajbiraj but they’re not going to have the money to go there because they’re Dalits and

they’re poor. They go to the traditional healers in times of need.”


8.6 Social Capital

Both Dalits and Non-Dalits note “social capital” as key to accessing better care and in addressing

barriers to access. Primarily, social networks are sources of information about services and

diseases. The information and incentives received at the point of health care access in a

government facility depend on who accompanies a patient and the perception of his level of

influence in the community and sometimes in politics. If a patient has a personal relationship

with someone in the health care system, they will often be guaranteed better access to treatment,

incentives, and medicines, as this non-Dalit woman reports, saying, “the doctors look at the

person, and see how influential he/she [is], and then decide to give free medicines or not.” It is

also echoed by a non-Dalit man, who is keen to point out his personal experience: “I saw it with

my own eyes that if one knows someone at the Biratnagar Hospital you get better treatment, free

medicines and treatment.”

This question of influence brings together the nexus of socio-economic factors being examined,

in that Dalits that are becoming politically active and are engaging in economic activities that

improve their income levels are garnering a position of higher socio-economic status, granting

them the benefits of being influential. A Dalit man remarks of a fellow community member,

“…because he's more well-known of a Dalit, for him they'll consider it and give him the

medicine, but for other Dalits who don't have a social position they'll mistreat him and give him

medicines late.” This is widening the gap within the Dalit community between the influential

Dalits and the lowest castes of Dalits, though this has also proven to be an opportunity for Dalit

community members to build a greater network of social capital and support the most

marginalized in accessing health care services.

There are financial implications of this as well: non-Dalits can take loans from parents or other

financially secure members of their networks, while Dalits reported greater difficulties obtaining

loans due to their stagnation within less financially secure networks. Instead, Dalits attempt to

pool money from their community, though it is often insufficient to cover the costs of accessing

health care. There are, however, cases where Dalit and non-Dalit members of the community

help one another in this respect, in terms of sharing information and of non-Dalits advising Dalits

on conditions and services. Non-Dalits are also able to provide loans to Dalits through joint

savings and credit cooperatives in some cases, which may be a potential point of entry for

utilizing social capital in a positive manner.

8.7 Discrimination

The fifth and final dimension used to examine access was discrimination. Two experiences

poignantly capture the main findings surrounding this issue. A Dalit woman in the village of

Chinnamasta gave the following account:

“The doctors in the village are Yadavs and Chaudhary caste.

When poor people like us go and ask for medicines, they send us

away saying that there are no medicines. But when other caste

people or rich people go, they get medicines.”


In this instance, and in this particular community, a distinct act of discrimination towards Dalits

took place. Another example of clear discriminatory acts towards Dalits was provided by a non-

Dalit man in the community of Malhaniya. When asked whether Dalits were treated different at

medical centers, he responded saying: “Yes, they don’t speak properly to Dalits. They just drive

them away, tell them there is no doctor.” At the point of treatment, the examples of clear-cut

discrimination took on various manifestations through denial of services and referrals, acts of

violence, displays of disrespect. Only in one case was “untouchability” mentioned in the context

of receiving treatment. Notably, the most extreme and distinct examples of discrimination

occurred in the communities of Chinnamasta and Malhaniya.

Nevertheless, while these were not isolated events, overall there were very few explicit examples

of direct caste-based discrimination at the point of treatment. That said, while there were few

instances of discrimination at the point of treatment, there were many more subtle acts of caste-

based discrimination relating to accessing care. These included things such as denial of loans (or

raising interest rates) to Dalits because of their caste affiliation, denial of services, or health

professionals refused to enter Dalit homes, as is indicated by the following conversation in the

community of Kanchanpur:

Interviewer: “When these [vaccination] campaigns happen do

these workers enter [your] homes? So if someone’s sick, will they

go in to help take care of them?”

Dalit Man: “Nobody comes in [our] house.”

The findings and methodology also suggested that caste was always framed in the language of

poor vs. non-poor or poor vs. rich (i.e. Dalits were poor and non-Dalits were the non-poor or

rich). This was both contextual, but also resulted from the fact that the topic of discrimination

was brought up using softer language in the translation. By inference, if this stratification was

included as a proxy for Dalit and non-Dalit, there are even more instances of discrimination, at

both the point of treatment and overall access opportunities.

It is important to note that this treatment also occurred mostly at government facilities, and less

so at private and other health institutions where provisions of care were contingent on payment.

It comes as no surprise, therefore, that where services are meant to be free (at government-run

facilities), Dalits were confronted with more frequent denials of service than at places where

payments were expected. Illustrated distinctly by the following statement by a Dalit woman,

money and purchasing power are the keys to receiving care- irrespective of caste and the facility

approached:

“… They go inside the house, the doctor is from the non-Dalit but

they are professional so they charge the money and come inside.

The money is the main factor to divide the Dalit and non-Dalit. If

they give the money to the government doctors they come in the

night- yes, if you give them extra money they come at night instead

of during the day.”


IX. Recommendations

The recommendations derived from this research are founded on the Samata Foundation mission

as a social inclusion think-tank and advocacy organization, and as such they are presented within

two categories: Policy Advocacy and Partnerships. This section further includes a developed

strategy on how Samata Foundation can advance these recommendations through partnerships.

9.1 Policy Advocacy

Recognizing the strengths and capacity of Samata Foundation to advocate for changes to

government policy to increase inclusiveness for marginalized groups, namely Dalit communities,

the research and data gathered and analyzed here can serve to importantly assist Samata

Foundation in informing policy recommendations.

Under this category are recommendations for modifications to the existing system that Samata

can advocate for in order for the government to achieve its goals of social inclusion outlined in

the NHSP-IP II and to fulfill its commitment to the Millennium Development Goals.

1. Strengthen internal and external monitoring mechanisms, leading to increased

transparency and accountability.

a. Internally:

i. Strengthen the system’s internal monitoring mechanism by supplementing

the existing channels through which grievances can be heard by an

additional channel to encourage potential whistleblowers;

ii. Establish a vigilance body, whose sole responsibility is to act on the

complaints raised through existing channels. This body may be given

powers to reprimand offenders;

iii. Establish a more reliable monitoring mechanism or body to ensure

accurate record keeping and transparency at all levels, creating reliable

channels of accountability.

b. Externally:

i. Encourage public monitoring of this system to ensure this accountability

and transparency translate to the public sphere;

ii. Pursue legislation requiring public institutions to provide written

information about their activities to any citizen who requests such

documentation (which can be modelled after the successes of India’s Right

to Information Act);

iii. In tandem with its partner organization, Jagran Media Centre, encourage

its network of grassroots journalists to monitor the system. This can be

done by adapting the existing program through which grassroots

journalists report on a weekly basis any story of discrimination against

Dalits, but focusing the program on specific instances of corruption and

failures of the health care system, not only in the national media but also

through local media (newspapers, FM radio, and TV).


iv. In reference to the MDGs, further examination is needed to assess if

Nepal’s achievement of the MDGs are reflecting the improvement in

marginalized communities.

2. Include Dalits in decision-making at the local level through participation in user groups,

VDCs, and DDCs to allow them a chance to participate in making decisions regarding

health care facilities and budgeting.

3. Improve health education for:

a. Doctors – local doctors that understand local contexts (including Dalit doctors and

female doctors) with MBBS degrees should be accessible to remote communities,

which may be accomplished through a government system of support for medical

school education in exchange for a number of years of service with marginalized

populations;

b. FCHVs – as the first point of contact for communities, FCHVs require on-going

field-based training and education programs so they are able to better inform the

communities on conditions, causes, and cures as well as government services;

c. Community – this can include programs based on sanitation and hygiene,

nutrition, literacy, government services, and health care access points;

d. Schools – work with the Ministry of Education to strengthen existing health

education programs within schools to stop the generational issue of lack of

information.

4. Advocate for grassroots self-reported recommendations addressing needs of local

communities:

a. Examples include mobile clinics for remote areas, a refund system for

reimbursement of incentives, efforts to establish 24-hour service delivery options

and staff at government facilities, improved infrastructure to improve access,

ambulances, and improved facilities including more beds, more doctors, female

doctors, and updated equipment such as x-ray machines.

9.2 Partnerships

At the same time, it is important to recognize a holistic approach to addressing health care access

that is inclusive of both the development and human rights spheres. We recommend the

establishment of partnerships for joint projects that address both human rights and development

through education, implementation, and funding. In this way, with Samata Foundation focusing

on human rights concerns and development agencies focusing on capacity development,

partnerships at all levels – with local community-based, national, and international non-

governmental organizations – Samata Foundation can contribute to the ongoing human rights

and development dialogue.

This set of recommendations addresses how Samata Foundation can integrate their policy

advocacy with development initiatives through informing partnerships with local, national, and

international bodies.


1. Conduct Human Rights community-based education to complement policy advocacy in

partnership with local organizations working on education with marginalized

communities. These can be modelled after “know your rights” programs that have proven

effective in other similar contexts that entail workshops on particular health rights and the

best way to secure those rights, grievance policies, information forums, and more. The

idea behind this program is that if people are more aware of their rights then they might

exercise them more often or be more successful at securing their rights when challenged.

2. Encourage the formation of women's groups, both informally but also through the formal

institution of mothers’ groups intended to be established by the government’s FCHVs.

Where they are established, these groups have proved successful in Saptari at addressing

issues that women face and improving knowledge regarding mother and child health by

educating women to become community ambassadors.

3. Share research results and tools with the Gender and Social Inclusion team with the

Ministry of Health to inform policy through this channel, and potentially form a

partnership to support their interest in scaling up this research nationally.

4. Use the findings of this research to inform donors and implementers supporting

development programming in order to channel resources towards needs and gaps in the

system.

A Note on MDGs:

In approaching both the government and partners, it will be important for Samata Foundation to

highlight the necessity of meeting Nepal's commitment to the Millennium Development Goals

(MDGs). Three MDGs relate directly to health care: reducing child mortality, improving

maternal health, and combating HIV/AIDS, malaria, and other diseases.68

While development

indicators may be improving in other parts of the country, the Terai is lagging behind national

averages. As those with improved socio-economic status can afford accessing better health care,

the disadvantaged remain further marginalized by the growing gap between those who have the

means to access care and those who do not. This research indicates that, by focusing attention on

health care access for the most marginalized, particularly Dalit communities, this gap can be

addressed leading to a dramatic advancement in health status of poorer communities. In this way,

Nepal can, in a sustainable and real way, improve health care indicators and meet the targets set

out by the MDGs, enhancing Nepal's reputation internationally.

68 UN Department of Economic and Social Affairs. “Official List of MDG Indicators”. Web 14 Feb 2012.

<http://mdgs.un.org/unsd/mdg/Host.aspx?Content=Indicators/OfficialList.htm>.


9.3 Strategy

The strategy outlined here highlights the opportunity for Samata Foundation to be the catalyst of

change towards mobilizing various institutions in Nepal to work towards empowering Dalits and

making the health system more inclusive of them. This is the holistic vision of potential methods

to achieve this, with five thematic foci, as well as specific preliminary recommendations and

potential partners for doing so.

Dialogue Inform funding,

programming, and

discourse around

health care as a

human right

Public Inclusion

Space for dialogue on

health issues,

accountability, and

transparency

Advocacy Stronger, more

transparent health

care system adaptive

to socioeconomic

conditions

Health Education

Increased community awareness on health

issues and services

Human Rights Education Community

advocates for itself

SAMATA

FOUNDATION


Themes for Action

A. Human Rights education

B. Health education

C. Advocacy

D. Public inclusion

E. Dialogue on Health as a Human Right

Action per Theme

A. Human Rights education

1) Goal: Community advocates for itself

2) Potential activities:

a. “Know Your Rights” workshops

b. Education campaigns

3) Potential partners and capacities:

a. Local community-based organizations (existing and new partnerships)

i. Access to community

ii. Knowledge of local communities

iii. Programs in place to build on

iv. Existing networks within communities and with other organizations

b. Media

i. Strong existing partners

ii. Wide reach and community influence

B. Health education

1) Goal: Increased community awareness of health conditions and available government

services


a. Nutrition and sanitation campaigns

b. Training for FCHVs

c. Women’s groups to discuss female health issues with experts

d. Strengthened health education campaigns in schools


a. Development organizations (existing and new partnerships)

i. Programs in place to build on

ii. Existing networks within communities and with other organization

b. Ministry of Health


i. Financial and human resources

ii. Country-wide reach

c. Ministry of Education

i. Access to students within schools

d. Media



C. Advocacy

1) Goal: Stronger, more transparent health care system adaptive to socioeconomic

conditions


a. Recommend the creation of a monitoring body for accountability within the

health system at all levels

b. Encourage that the health system address the particular socioeconomic

disadvantages of Dalits in addition to overt discrimination


a. GESI team with Ministry of Health

i. Mandate to ensure health system and Ministry of Health is sensitive to

gender equity and social inclusion

ii. Financial and human resources

iii. Country-wide reach

iv. Existing partnership

D. Public inclusion

1) Goal: Space for dialogue on health issues, accountability, and transparency


a. Increase accountability and transparency of health care system by allowing the

public to interact with the system and obtain any information requested, acting as

an external monitoring mechanism

b. Create a space for dialogue on issues relating to health and the health care system

and a space for the public to voice concerns to the government

c. Advocate for inclusion of Dalits in decision-making levels within the health care

system in terms of resource allocation


a. Media



iii. Interest in improving transparency

b. GESI with Ministry of Health


i. Mandate to ensure health system and Ministry of Health is sensitive to

gender equity and social inclusion

E. Dialogue on Health as a Human Right

1) Goal: Inform funding, programming, and discourse around health as a human right


a. Engage in the international dialogue around health as a human right and create

more spaces for this discourse

b. Present the findings of this research to development organizations to inform and

target their funding and programming

c. Continue to monitor the progress of Nepal on achieving health and human rights

indicators, including the MDGs


a. International organizations

i. Interest in fulfilling MDGs

ii. Existing partnerships with UNICEF and DFID

b. Local researchers at Samata

i. Opportunity to build local capacity

c. Media

i. Ability to engage public in dialogue and increase awareness on the

development status of Nepal

d. GESI with Ministry of Health

i. Interest in utilizing findings to inform Ministry of Health policy and

expand research


X. Conclusions

The research presented here examined and identified health care access for Dalits in six

communities of the Saptari District in the Terai region. By examining the NHSP-IP II and the

formal and informal structures of the health system, it was revealed that both Dalits and Non-

Dalits are disadvantaged in access to health services due to systemic weaknesses of the health

care system. Within the policy research findings, it appears that the trickle-down effect and the

implementation of policies such as NHSP-IP II are limited. The policy addresses the importance

of reaching these services to marginalized communities such as Dalits, but the implementation

fails to effectively reach the populations it intends to serve. With the recent decentralization of

health care services, the need for a strong checks-and-balances mechanism to address the

shortcomings of the system is crucial for improved delivery.

While implementation of policy is limiting and the health structure remains weak, the research

revealed that Dalits are at a disadvantage in all five dimensions of access to health care services,

namely physical access, information access, financial access, discrimination, and social capital.

The nexus of these factors results in the weaker socioeconomic status of Dalits that compounds

their barriers to accessing health care. As a result, in order for the Government of Nepal to

successfully address the delivery of health care services to the Dalit population, it is vital that

these dimensions of access and its relations to the Dalit population are considered. It is essential

for policy makers to take into account these compounding issues that create disadvantage for

Dalits and initiate a multi-faceted policy so the right to health can be successfully achieved for

Dalits. It is in this vein that Samata Foundation should gear its programming in order to further

inclusive health care access and policies for marginalized Dalit communities.


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ANNEX I: Background – Tables and Maps

Table 2: Gender differentials in National child health

Indicators Year Male Female Ratio F/M

Under 5 Mortality Rate

(per 1,000 live births)

1996 142.8 135 0.95

2006 80 78 0.98

Infant Mortality Rate (per

1,000 live births)

1996 101.9 83.7 0.98

2006 60 61 1.02

Neonatal Mortality Rate

(per 1,000 live births)

1996 65.6 50.4 0.77

2006 39 37 0.95

Stunting Rate (% of

children with height to age

ratio under below 2

standard deviations of the

median)

1996 46.6 50.2 1.08

2006 49.0 49.6 10.1

Immunization coverage

(% of children immunized)

1996 46.7 39.9 0.85

2006 84.9 80.6 0.95

Prevalence of Acute

Respiratory Infections

(per 1,000 children)

1996 34.6 33.6 0.97

2006 506 4.9 0.88

Prevalence of diarrhea


1996 28.7 26.2 0.91

2006 12.8 10.9 0.85

Coverage of Medical

Treatment of Acute

Respiratory Infections


1996 18.2 18.2 1

2006 42.2 43.8 1.04

Coverage of Medical

Treatment of diarrhea


1996 14.7 12.9 0.88

2006 29.1 24.3 0.84

Source: Ministry of Health and Population (MOHP) [Nepal], New ERA, and Macro International Inc. (2007)


Map of Nepal:

Source: Ezilon Maps: http://www.ezilon.com/maps/asia/nepal-physical-maps.html


ANNEX 2: Map of Communities


ANNEX 3: Table of Timeline of Relevant Policies, Plans, Framework, and Agendas

First 5-Year Plan (1956-1961)

Third 5-Year Plan (1965-1970)

Nepal Government’s National Health Policy (1991)

Eighth 5-Year Plan (1992-1997)

Ninth 5-Year Plan (1997-2002)

Second Long Term Health Plan (SLTHP) (1997-2017)

Millennium Development Goals (2000)

Tenth 5-Year Plan (2002-2007)

Health Sector Strategy: An Agenda for Reform (2003)

Nepal Health Sector Program- Implementation Plan (NHSP-IP) (2004-2010)

Eleventh 5-Year Plan (2007-2012)

Gender Equality and Social Inclusion Framework (GESI) (2009)

Nepal Health Sector Program-Implementation Plan (NHSP-II) (2010-2015)


ANNEX 4: Stakeholder Analysis

Stakeholder Stakeholder's status/ role Likely Attitude

Capacity and Resources related to health care services Importance Influence

Samata Foundation Client Favorable

Access to Dalit communities in the field. Intermediary between grassroots and mid-level policy makers. High Moderate

UN Affiliated Organizations

World Health Organization

Technical and Financial Support for Government of Nepal Favorable

Technical and financial capacities. High Moderate

UNICEF ROSA/Country Office

Technical and Financial Support for Government of Nepal Favorable

Advocacy, social mobilization, Technical and financial capacities. High Moderate

NGOs


Sabal

Local NGO that works on water and sanitation issues in local communities. Favorable

Grassroots network and access to local communities in the field. High Moderate

FEDO

Local NGO that works to empower and advocate for Dalit women. Favorable

Grassroots network and access to local communities in the field. Experience in advocating for pro-Dalit female policy. High Moderate

Government

Ministry of Health

Creates health related policies and supervises on its implementation. Favorable

Technical and policy related capacities. Ability to implement and change policy. High High

Gender and Social Inclusion Team (GESI)

Interested in using our tools and findings for their research on inclusion. In the midst of creating an action plan for gender and social inclusion. Favorable

Technical and policy related capacities. Ability to influence policy and implementation. Funded by World Bank, Asian Development Bank and UK-DFID. Moderate High


Planning Committee

Responsible for assessing the development of Nepal and creating policies. Favorable

Provides the guidelines for planning and development. Technically focused. Moderate High

District Development Office

Supervises the implementation of development policies and programs on district level. Favorable

Access to district level. Technical and policy implementation knowledge. Moderate Moderate

District Health Office

Supervises the implementation of health policies and programs on district level. Favorable

Access to district level. Technical and policy implementation knowledge. Moderate Moderate

Village Development Committee

Oversees the implementation and programmes provided to the village level. Works with local villages for development projects. Favorable

Local knowledge and access to communities. Moderate Moderate


Formal Health Structure Facilities

Zonal and District Hospitals

Upper level health access points. Secondary level of care from Central and Regional Level.

Favorable (better care and services); Unfavorable (revealed flaws of system and service)

Technical capacity. Health care service provider. Moderate Moderate

Sub Health Post/ Health Post

Electoral Constituency level with primary health care services.


Technical capacity. Health care service provider. Moderate Moderate

FCHVs

Community health extension volunteers responsible for basic health services such as distribution of iron and vitamin pills, vaccinations, and education on family planning, maternal health.


Access to the community level. Health care service provider. Moderate Moderate

Informal Health Structures


Traditional Healer

Part of alternative informal structure of Nepali health care system. Favorable

First and last access point of health care for many Dalits. Access to communities. Respected and trusted in communities. Moderate Moderate

Mother's Groups

Informal group of women working on village level. Assists the FCHV in the community. Favorable

Capacity for social networks. Access to communities. Moderate Moderate

Pharmacists

Individual store keepers that buy and sell pharmaceutical products. Not affiliated with the Government. Perhaps Favorable

Provider of supplies and resources for patients and providers. Sells medicine for personal profit. Moderate Moderate

Private Hospitals/Clinics

Doctors with own private clinics that provide health services for a cost. Sells medicines at these clinics. Perhaps Favorable

Informal provider of health care services. Moderate Moderate


Beneficiaries

Dalit Leaders Beneficiaries Favorable

Ability to influence and reach Dalit populations. Access to local Dalit communities. High Low

Dalit Communities Beneficiaries Favorable

Able to share firsthand experience of access to health care services. Information-sharing. High Low

Non-Dalit Communities

Higher-caste individuals and communities outside the "Dalit" population.

Perhaps Favorable. Depends on individual perceptions and beliefs.

They can be either supportive or unsupportive of the policies. Therefore serve as a barrier or catalyst for change. Low Moderate

Political Parties

Local Political Parties

Local Political Parties that mobilize in local areas.

Perhaps Favorable. Depends on political parties' perceptions, goals and beliefs.

Ability to mobilize communities. Push for certain agendas. Moderate Low


National Political Parties

Major Political Parties that mobilize near the capital, Kathmandu.

Perhaps Favorable. Depends on political parties' perceptions, goals and beliefs.

Ability to mobilize communities. Pressure government and ministries for policy change. Moderate Low

Media

Local Media Local newspapers and Dalit reporters. Favorable

Sensitization and highlighting the issues. Can help promote accountability and pressure for government to take action. Ability to spread information and reach vast populations. Moderate Low

National Media

National newspapers, TV and radio sources. Perhaps Favorable

Sensitization and highlighting the issues. Can help promote accountability and pressure for government to take action. Ability to spread information and reach vast populations. Moderate High


Scholars, Experts, and Academia

Local and foreign experts in the fields of health, policy and research. Favorable

Influence research and new findings. Can advise the Government on policies and action plans. Moderate

Moderate/ Low

Missionaries

Foreign missionaries that work on humanitarian aid- health services and education in rural communities. Favorable

Spread awareness, education and service provisions. Moderate Moderate


ANNEX 5: Institutional Analysis

Level Organization Rules/Policies Activities Constraints Coordination/Communication

Central Ministry of Health

Second Long Term Health Plan 1997-2017

Expand health institutions, formulate policies. Establish relationships with foreign countries and institutions. Maintain data and statements regarding health services. To ensure supply of drugs, equipment, and other material at regional level by properly managing these resources.

Financial constraints in allocation relating to health services.

Communicates directly to regional levels. Communicates to international organizations, institutions and foreign countries.

Regional

Regional Training Center, Hospital, Facilities

Established in 1993 but the roles of regional health directorates are unclear and have had little impact to date.

Support MoH in training and implementing policy related initiatives.

Financial constraints in health services.

Communicates to Zonal hospitals. Receives information directly from the Center.


Zonal Zonal Hospital 15 Regional and Zonal hospitals.

Secondary level of care.

Lack of staff and resources. Medicines are often exhausted during the first few months of the fiscal year. Corruption.

Reports to Regional and MoH.

District


Assists in the funding of health related initiatives. Responsible for the development and wellbeing of its district.

Guide the VDC in programs and funding. Support FCHV in local funds.

Lack of funding. Opaque processes and decision-making.

Reports to Central Planning Committee and collaborates with local VDCs.

District Hospital

Serves as advanced health care for district. Testing facilities, human resource and equipment to treat more advanced forms of diseases.

Secondary level of care.

Lack of staff and resources. Medicines are often exhausted during the first few months of the fiscal year. Corruption. Communicates to DHO.



Oversees PHC, HC, HP and SHP.

Support FCHVs by strengthening their capacity through trainings and commitment.

Management and finance controlled by center.

Communicates directly to regional and center. Supervises all community and electoral level units of health care.

Electoral

Constituency

Primary Health Care Centre/ Health Centre

Consists of 1 doctor and 1 assistant health worker.

Free TB services, blood and urine testing, 32 free medication and services.

Lack of staff and resources. Medicines are often exhausted during the first few months of the fiscal year. Corruption. PHCs report to DHOs.

Health Post Consists of health assistant and ANC.

Primary health care services.


Health Post reports to PHCs.


VDC VDC

One VDC per ward- consists of 1 elected chief, 1 ward chief, 4 ward members, 1 village secretary who is appointed by government

Manages utilization and distribution of state funds to local levels. Collect and monitor data for census. Support FCHV in local funds.

Opaque processes and decision-making. Lack of funding.

Status as an autonomous institution and authority for communicating with centralized institutions.

Sub Health Post

First contact point for basic health services

Primary health care services.


Sub Health Post reports to the Health Post and PHCs.

Community FCHV

National FCHV Program Strategy 2003. 1 FCHV in every ward nationwide, who is knowledgeable, trained and well supported health resource person.

Distribution of iron pills, vaccines, and other program related functions as directed by the DHO such as maternal health, family planning, child health and infectious diseases.

Lack of knowledge and adequate training to advise communities. Respect from communities varies. No monetary incentives. Lack of resources to distribute among communities.

FCHVs report to the Sub Health Posts for data collection, resource accumulation and program implementation.


Mothers Group

Informal women's group that nominates FCHV and supports her work in the community.

Supports FCHV activities in village level. Assists community through savings and credit loans.

Inclusive group of women that tend to be connected through marriage, relations, etc. Difficult for marginalized community members to participate.

Communication is directly with FCHV of that area.


ANNEX 6: List of Organizations and Individuals Interviewed Through KIs or FGDs

Kathmandu, Nepal

Feminist Dalit Organization (FEDO)

Gender and Social Inclusion Team, Government of Nepal

Jagran Media Centre

Medical Anthropologist

Ministry of Health, Government of Nepal

National Non-Dalit Journalists

Patan Academy of Health Services (Professor)

Planning Committee, Government of Nepal

Samata Foundation

United Nations Children’s Fund- Regional Office for South Asia

World Health Organization

Saptari (Communities in Rajbiraj, Kanchanpur, Joginya, Chinnamasta, Malhaniya, Khojpur)

Dalit Women and Men



FCHV

Local Dalit Reporters

Local Government Employees

Non-Dalit Women and Men

Nurse

Pharmacists

PHC

Retired Government Workers

SABAL Nepal

School (Headmaster)

Sub-Health Post

Traditional Healers

United Nations Children’s Fund- Nepal (Field Staff)

VDC Secretary

VDC Worker

USA

UN Women Headquarters

Innovations for Successful Societies

Columbia University School of Public Health (Professors)


ANNEX 7: Survey Data on Health Status in Terai

*Based on survey of 395 members of various Dalit castes conducted by Samata Foundation in

2001 in communities across the Terai, namely Saptari, Dhanusha, Parsa and Moran districts.


Annex 8: Common Diseases in Dalit and Non-Dalit Communities in Saptari District *Based on reports from FGDs of surveyed communities in six communities in Saptari

Top Diseases in Dalit Communities

Dalit

Joginya Joginya Chinnamasta Chinnamasta Malhaniya Malhaniya Khojpur Khojpur Rajbiraj Total

Median Ranking

Number mentioned

(d) Pneumonia 1 1 3 3 1 3 1 13 1.44 7 (d) Diarrhea 3 3 0.33 1

(d) Gastric 4 5 4 5 18 2.00 4

(d) Cough/Asthma 5 1 4 10 1.11 3

(d) White Water 2 4 3 4 1 14 1.56 4

(d) TB 2 3 1 5 5 3 19 2.11 6

(d) Malaria 4 4 0.44 1

(d) Kala-azar 2 2 0.22 1

(d) Leprosy 2 2 0.22 1

(d) Yellow Fever 4 4 0.44 1

(d) Malnutrition 1 1 0.11 1

(d) Blood Cancer 2 2 0.22 1

(d) Arthritis 4 4 0.44 1

(d) Pregnancy 2 2 0.22 1 (d) Dental/Cancer 5 5 0.56 1

(d) Health disease 2 3 5 0.56 1

(d) Uterus problem 2 2 4 0.44 1

(d) Whole body swelling 3 3 0.33 1

(d) Cancer 1 1 0.11 1

(d) Diabetes 5 5 0.56 1

(d) Fever 5 5 0.56 1

(d) Ear problem 4 4 0.44 1


Top Diseases in Non-Dalit Communities

Non-Dalit

Kanchanpur Joginya Chinnamasta Malhaniya Khojpur Rajbiraj Total Median

Rank Number

mentioned

(nd) TB 1 4 2 1 8 0.8 4

(nd) Uterus Prolapses 2 1 3 6 0.6 3

(nd) Pregnancy 3 5 4 1 13 1.3 4 (nd) Diabetes 4 1 2 7 0.7 3

(nd) Cancer 5 3 2 5 15 1.5 4

(nd) Gastric 2 2 3 1 8 0.8 4

(nd) Blood Pressure 3 4 7 0.7 2

(nd) Miscarriage 4 4 0.4 1

(nd) Pneumonia 5 5 2 1 1 2 16 1.6 6

(nd) Child Illness 2 2 0.2 1

(nd) Child Mortality 3 3 0.3 1

(nd) Weakness 4 4 0.4 1

(nd) White water 1 3 5 9 0.9 3

(nd) Fever and Cough 3 4 4 11 1.1 3 (nd) Toothaches 4 4 0.4 1

(nd) Diarrhea 1 5 3 9 0.9 3

(nd) Chicken Pox 5 5 0.5 1

(nd) Eyes and Ears 4 4 0.4 1

(nd) Asthma 5 2 7 0.7 2

(nd) Nerves Hurt 3 3 0.3 1

health is wealth: health care access for dalit communities

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